Physician documentation drives many critical processes in patient care delivery. Electronic documentation presents extraordinary opportunities to improve these processes, but brings with it a host of challenges. We review the different document types, their uses, and the pros and cons of different data input methods by which physicians can document in the EMR.
Clinical documents also serve many purposes, such as supporting communication among caregivers, providing legal protection, and supporting coding and billing. The secondary use of data collected during documentation is vital to multiple other processes including reporting of quality indicators, driving clinical decision support, and supporting analytics based on aggregate data.
In this report, we review the uses of physician documentation in inpatient and ambulatory settings. We will examine the different possible data input methods that can be used to populate these documents, the different document and field types, the effects of each input method on the value of the data collected for different uses, and the advantages and disadvantages of each input method.